Let’s Get to the Root of Your Hair Concerns "*" indicates required fields Step 1 of 11 9% What is your email?* Are you currently an active patient in Ness’ weight loss program?* No Yes Would you like to bundle your hair loss medication with your medical weight loss prescription?*We highly recommend bundling with our medical weight loss program, as you can save up to 45% off your medication. No Yes How satisfied are you with your hair overall?* Not at all A little bit Somewhat Quite a bit Very What are your top priority goals for hair loss treatment?* I want to prevent further hair loss I want to regrow hair I want fuller, thicker-looking hair I have a full head of hair I’d like to maintain Where are you noticing hair loss or thinning?*Both hairline and crownReceding hairline (along my forehead or temples)Thinning crown (top of my head)Overall thinningRandom golf-ball size bald patches scattered all over scalpNowhere yet, but I’d like to prevent future hair loss Have you ever treated your hair loss with medication?* No Yes What treatments did you receive?* Oral Minoxidil Topical Minoxidil or Rogaine Oral Finasteride or Propecia Topical Finasteride Steroid injections in the scalp Other Please tell us more about your treatment experience (effectiveness, side effects, etc.)* Have you noticed any of the following? (Please check off all that apply)* None of these Redness or rashes on scalp Pain Soreness Burning, and/or tingling in areas of hair loss Recurrent pus bumps or open sores on scalp Partial or complete loss of eyebrows or eyelashes Loss of body hair Have you ever been diagnosed with or treated for high or low blood pressure?* No Yes, I have been diagnosed or treated for high blood pressure Yes, I have been diagnosed or treated for low blood pressure I’m not sure Do you have, or have you ever had, any of the following conditions? (Please check off all that apply)* None of these Heart failure Pericarditis Benigin prostatic hyperplasia Repeated chester pain or tightness, also called angina Arrhythmia or abnormal heart rhythm Coronary artery disease, or narrowing of the heart vessels Coronary bypass surgery Heart attack Stroke Pheochromocytoma (adrenal gland tumor) Pulmonary hypertension Prostate cancer Kidney disease Liver disease Erectile Dysfunction Anxiety Depression Eczema Please list any prescription medications, over-the-dounter medications, vitamins, dietary supplements, and topical creams you are currently taking or using, including dosages. Please type N/A if none.* Are you allergic to any of the following? (Please select all that apply)* Finasteride (oral or topical) Minoxidil (oral or topical) Ketoconazole (oral or topical) Latanoprost None of the above Please list all of your known allergies. Please type N/A if none.* Tell Us About YourselfName* First Last Phone Number*Date of Birth* MM slash DD slash YYYY Sex at Birth* Female Male Please upload a government-issued form of ID (Driver’s License, Passport, etc.). Please be sure that your full name and photo are easily visible.*Max. file size: 5 MB.What type of consultation would you prefer?*Email and Text Message (Fastest Option)VideoPhone CallHow did you find Ness?* Consent*Please attest to the following confirming that all the information you provided is true and complete. If you do not agree, you may not submit this form. I confirm that I am the patient completing this intake form and have reviewed all questions carefully. I attest that my answers are true, accurate, and complete to the best of my knowledge. I understand the importance of providing my doctor with complete and accurate health information for my care. I agree and consent Ness doctors review every form within 24 hours. Do you have any further information which you would like the doctor to know? One Last StepWe'll securely collect your payment information now, but you won't be charged until your intake form has been reviewed. If you qualify for medical weight loss, your first month’s prescription will be billed at that time. If you're not eligible, a $30 non-refundable evaluation fee will be charged to cover the cost of the medical review.Referral Code (if applicable)Shipping Address* Street Address Address Line 2 City AlabamaAlaskaAmerican SamoaArizonaArkansasCaliforniaColoradoConnecticutDelawareDistrict of ColumbiaFloridaGeorgiaGuamHawaiiIdahoIllinoisIndianaIowaKansasKentuckyLouisianaMaineMarylandMassachusettsMichiganMinnesotaMississippiMissouriMontanaNebraskaNevadaNew HampshireNew JerseyNew MexicoNew YorkNorth CarolinaNorth DakotaNorthern Mariana IslandsOhioOklahomaOregonPennsylvaniaPuerto RicoRhode IslandSouth CarolinaSouth DakotaTennesseeTexasUtahU.S. Virgin IslandsVermontVirginiaWashingtonWest VirginiaWisconsinWyomingArmed Forces AmericasArmed Forces EuropeArmed Forces Pacific State ZIP Code Is your shipping address the same as billing?* Yes No Billing Address Street Address Address Line 2 City AlabamaAlaskaAmerican SamoaArizonaArkansasCaliforniaColoradoConnecticutDelawareDistrict of ColumbiaFloridaGeorgiaGuamHawaiiIdahoIllinoisIndianaIowaKansasKentuckyLouisianaMaineMarylandMassachusettsMichiganMinnesotaMississippiMissouriMontanaNebraskaNevadaNew HampshireNew JerseyNew MexicoNew YorkNorth CarolinaNorth DakotaNorthern Mariana IslandsOhioOklahomaOregonPennsylvaniaPuerto RicoRhode IslandSouth CarolinaSouth DakotaTennesseeTexasUtahU.S. Virgin IslandsVermontVirginiaWashingtonWest VirginiaWisconsinWyomingArmed Forces AmericasArmed Forces EuropeArmed Forces Pacific State ZIP Code
